Free Microsoft Word - 52235_R-1-06_-Birthing Center Application original 011706.... - Indiana


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State: Indiana
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APPLICATION FOR LICENSE TO OPERATE A BIRTHING CENTER
State Form 52235 (R/1-06)

Indiana State Department of Health-Division of Acute Care (Pursuant to IC 16-21-2 and 410 IAC 27)

Form Approved By State Board Of Accounts-2006

Division of Acute Care Use Only Date Received__________________ Date Approved__________________ Date Rejected __________________

Please Type or Print Legibly SECTION I - TYPE OF APPLICATION Application (check appropriate item)
New Facility Renewal Change of Ownership (Anticipated date of Sale/Purchase/Lease)__________________ Submit a dated and signed copy of the bill of sale, lease or other document of transfer

SECTION II - IDENTIFYING INFORMATION A. Birthing Center Location
Name of Birthing Center

Street Address

P.O. Box

City

County

Zip Code +4

Telephone Number ( )

Fax Number ( ) Birthing Center e-mail address:________________________________________________________

Internet Web Address:______________________________________________________________

B. Mailing Address (if different from birthing center location)
Street Address P.O. Box

City

County

Zip Code +4

C. Licensee/Ownership Information
Licensee: The applicant entity as registered with the secretary of state

Street Address

P.O. Box

City

State

Zip Code+4

Telephone Number ( )

Fax Number ( )

EIN Number

Fiscal Year End Date (mm/dd)

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D. Facility, staff, and services provided under this license:

The facility is a:

Home

Professional Office Building ______Birth Rooms ______Kitchen

List numbers of each: ______Reception Area ______ Business Office ______Exam Room ______Whirlpool/Tub Room ______Bathroom ______Family Room

______ Classroom

______Conference Room

______Storage Room

______Playroom/area

Other: (specify)___________________________________

Staffing (number of ): Certified Nurse Midwives: ______ Registered Nurses (excluding CNMs): _______ Licensed Practical Nurses: ______ Obstetricians: ______ Family Practitioners: ______

Certified Birthing Educators: ______ Other: (Specify)

____________________________

Services Provided: (check all that apply) Orientation to fees and services Written glossary and criteria for admission and continuation in the program Prenatal care Education regarding pregnancy, labor, breastfeeding, infant care, early discharge, parenting, self-care/self-help, and sibling preparation 24-hour telephone consultation Library resources Intrapartum care Immediate Postpartum care Nourishment during labor Home or office follow-up for mother and newborn Exercise programs Parent support groups Postpartum classes Family planning Well baby care Circumcision Nursing mother support program Well woman gynecologic care Public education Clinical investigation/research Domestic violence education Onsite laboratory, if yes CLIA Certificate #_________________________________.
E. Charges: Practitioner Facility

Birthing Center: Hospital:

$__________.00 $__________.00

$__________.00 $__________.00

F. Type of Entity: For Profit
Individual Partnership Corporation Limited Liability Company Sole Proprietorship Other (specify) _____________________________ _____________________________________________ _____________________________________________ _____________________________________________

Non-Profit
Church Related Individual Partnership Corporation Limited Liability Company Other (specify) _____________________ _____________________________________ _____________________________________ _____________________________________

Government
State County City City/County Hospital District Federal Other (specify) ________________ ________________________________ ________________________________

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G. Officers (if the business entity is incorporated) Position President/Chairperson/CEO Vice-President/Vice-Chairperson/COO Treasurer/CFO Secretary

Name

Address/City/State/Zip

H. Ownership and/or Change in Ownership: List names and addresses of individuals or organizations having direct or indirect ownership or controlling interest of five percent (5%) in the applicant entity. Indirect ownership interest is an entity that has an ownership interest in the applicant entity. Ownership in any entity higher in a pyramid than the applicant constitutes indirect ownership. (use additional sheet if necessary)
Name Business Address/City/State/Zip EIN Number

CERTIFICATION OF APPLICATION The undersigned hereby makes application for a license to operate a Birthing Center (Center) in the State of Indiana, and in support of this application, represents and shows that the owner(s) and operator(s) are of reputable and reasonable character, are able to comply with the Birthing Center statue, IC 16-21-2-2.5, and the rules promulgated thereunder, 410 IAC 27 and will operate and maintain this center in accordance with those rules. I certify that the operational policies of the center will not provide for discrimination based upon race, color, creed, or national origin. I swear and affirm under the penalty of perjury that all statements made in this application and any attachments thereto are correct and complete and that I will comply with all regulations, laws, and rules governing the licensing of centers in Indiana. Signature of the Medical Director: Printed Name and Title: Date of Signature: Signature of the Center Administrator: Printed Name and Title: Date of Signature:

See the following page for instructions regarding licensure fees and submission of this application
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License Fee Based upon the number of births listed in item N of the Annual Birthing Center Report (State Form 52236), select the appropriate fee:

Check One

Total Births in the Center

Fee $500.00 $1,000.00 $2,000.00 $3,000.00

Zero to 799 800 to 3,499 3,500 to 6,999 7,000 and above Indiana Hospital Council; 414 IAC 1-1-4

Enclose the following: 1. A completed Application for License to Operate a Birthing Center (this form); 2. A completed Annual Birthing Center Report (State Form 52236); 3. Any supporting attachments; and 4. Payment made payable to "Indiana State Department of Health." Mail to: INDIANA STATE DEPARTMENT OF HEALTH CASHIER'S OFFICE P. O. BOX 7236 INDIANAPOLIS, INDIANA 46207-7236

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